Raymond J. Ashleigh

Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm

Single‐centre series of the management of patients with ruptured abdominal aortic aneurysm (AAA) are usually too small to identify clinical factors that could improve patient outcomes.

Device migration after endovascular abdominal aortic aneurysm repair: Experience with a talent stent-graft

PURPOSE Device migration (DM) may cause late failure after endovascular aortic aneurysm repair (EVAR). Computed tomography (CT) scans following EVAR were reviewed to establish the frequency of DM and whether it can be predicted. MATERIALS AND METHODS Fifty-five patients underwent EVAR with a Talent stent-graft with suprarenal fixation. CT with a fixed protocol was performed at regular intervals. Patient demographics, risk factors, procedure details, and follow-up events were reviewed. Two observers, blinded to each other, reviewed axial images and mutliplanar reformats of the CT scans. DM was defined as a change of > or = 10 mm in the distance between a reference vessel (celiac axis/superior mesenteric artery) and the proximal device. Follow-up was performed for a minimum of 2 years (mean, 3 years; range, 2-5 years). RESULTS DM was detected in six of 38 patients (15.8%) by 2 years. There were no new cases of migration in the 19 patients at 3 years but one new case in the six patients at 4 years (16.6%). Mean migration over 2 years was 4.8 mm +/- 4.2 mm. One patient with DM developed a type I endoleak that required reintervention. This patient developed a further endoleak and died following surgery for rupture. Top neck enlargement was the only predictive factor identified, present in 71% of patients with DM (P = .056). CONCLUSION DM occurred in a small proportion of patients; closer follow-up intervals may be necessary in patients with short/enlarging proximal necks.

Midterm follow-up of a single-center experience of endovascular repair of abdominal aortic aneurysms with use of the Talent stent-graft.

PURPOSE To review the midterm results of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Talent stent-graft. MATERIALS AND METHODS All patients who underwent EVAR of AAAs with Talent stent-grafts from February 1998 to April 2002 at a single institution were monitored for a minimum of 2 years or until an endpoint of death or rupture was reached. RESULTS There were 68 eligible patients, who were monitored for a mean period of 39 months (range, 24-72 months). Forty-nine (72.9%) were alive at 2 years; among the 19 deaths, two resulted from aneurysm rupture and the other 17 were unrelated to EVAR. There was one immediate conversion to open repair and five primary proximal endoleaks; the remaining 62 patients (91.2%) all had a technically successful procedure. There were 33 endoleaks during follow-up: 23 (69.7%) were treated conservatively and 10 (30.3%) underwent secondary intervention in the form of embolization (n=2), attempted embolization (n=2), endovascular stent-graft placement (n=3), combined stent-graft placement and embolization (n=1), or surgical conversion (n=2). Overall, there were five persistent endoleaks, and the remaining patients were free of endoleak at their last review or endpoint. Three stent-grafts migrated and required further endovascular intervention. Wire fracture was seen in two stents but presented no clinical sequelae. There was one case of graft limb thrombosis that required surgical thrombectomy. CONCLUSIONS EVAR of AAAs with use of the Talent stent-graft is a promising and acceptable alternative to open surgery. Our 30-day mortality rate of zero compares extremely well with historical data from open surgery and the findings of more recently published trials. The risk of endoleak and uncertainty over durability require long-term surveillance.

Endovascular Aneurysm Repair with the Talent Stent-Graft

PURPOSE Evaluation of the Talent endovascular aortic stent graft in the management of abdominal aortic aneurysms. MATERIALS AND METHODS Thirty-eight patients with suitable abdominal aortic aneurysms were treated over an 18-month period using the modular Talent stent graft. The suprarenal Talent device was deployed in 31 cases. Clinical follow-up of all patients has been performed by clinical examination, contrast-enhanced CT, and Duplex ultrasound for a mean period of 12.5 months. RESULTS Graft placement was successful in all 38 patients. The immediate exclusion rate was 84%, the 1-month primary exclusion rate was 92.1%, and the 3-month exclusion rate was 97%. There were no deaths in the first 30 days, one death at 3 months due to a presumed rupture, and one other death at 1 year due to carcinomatosis. There have been no migrations or renal complications in the suprarenal group. CONCLUSIONS Our short- and medium-term results are comparable with other published Talent stent-graft series. Suprarenal graft fixation is a safe procedure that may aid in preventing graft migration. Long-term follow-up is required to assess the durability of the suprarenal Talent device.

CT-Guided Embolization of an Isolated Internal Iliac Artery Aneurysm 8 Years after AAA Repair

Purpose: To report the use of computed tomographic (CT) guidance for percutaneous treatment of an isolated internal iliac artery (IIA) aneurysm after open aortic aneurysm repair. Case Report: A 74-year-old man presented with an isolated IIA aneurysm 8 years after an open repair of his abdominal aortic aneurysm. In view of his diabetes, hypertension, and chronic renal impairment, an endovascular technique was selected. However, because of previous ligation of the internal iliac origin, a transarterial approach could not be used. The proximity of the aneurysm to the anterior abdominal wall allowed us to gain access to it percutaneously using CT guidance to perform embolization. Conclusion: CT-guided direct puncture of isolated IIA aneurysms adds to the current armamentarium of minimally invasive modalities. It is a technique that can be applied to isolated IIA aneurysms that develop subsequent to AAA repair or appear in cases where intra-arterial access is not possible.

Endovascular stent graft: treatment of pseudoaneurysm of the superior mesenteric artery.

Splanchnic artery aneurysms are rare with an incidence of between 0.1 and 2% [1]. Superior mesenteric artery aneurysms (SMAA) are the third most common after splenic and hepatic artery aneurysms and represent approximately 7% of visceral artery aneurysms [2]. They are clinically important as rupture can result in fatal hemorrhage [2]. Previously described surgical management has included ligation, resection and/or bypass. Endovascular treatment has been mainly limited to transcatheter embolization. We describe a case of SMAA secondary to pancreatitis causing obstructive jaundice and treated by an endovascular stent graft, an approach not previously reported.

Multi-layer Flow-modulating Stents for Thoraco-abdominal and Peri-renal Aneurysms: The UK Pilot Study

OBJECTIVE There remains a population of patients with aortic aneurysms that cannot be treated by conventional endovascular means. Multi-layer flow modulating stents (MFMS) are a novel approach for the treatment of aortic aneurysm; this study reports outcomes of a UK pilot study of first-generation MFMS in thoraco-abdominal (TAAA) and perirenal aneurysms (PAA) in patients who were also unfit for open surgery. METHODS Patients with TAAA and PAA unfit for open surgery and with no conventional options for endovascular repair were recruited. Follow-up included CTA at 1, 3, 6, and 12 months, then annually. Outcome measures included 30 day mortality, growth-free survival, branch vessel patency, complications, re-intervention, and maximal aortic diameter. RESULTS MFMS were implanted in 14 patients (6 PAA, 8 TAAA) between October 2011 and March 2014 with one (7%) 30 day death and 11 (79%) surviving to 12 months. The median aneurysm growth was 9 mm in the first 12 months following implantation. On mean follow-up of 22.8 months, seven (50%) patients had died including one confirmed rupture. AAA diameter remained stable in only two of the surviving patients. Fifty of 51 covered aortic branches remained patent with no embolic episodes or symptoms of ischaemia in any patient. MFMS dislocation occurred in four patients, leading to re-intervention in two. A total of six re-interventions were performed in five patients (35%) with one post-re-intervention death. CONCLUSION These first-generation MFMS were unstable and dislocated frequently. It is uncertain whether MFMS implantation influenced the natural history of these aneurysms as none decreased in size, but two remain stable after a mean of 22.8 months. Although side branch patency was maintained, our results do not support the continued use of these first-generation devices. Further development is needed if this technology is to have a role in treatment of aortic aneurysm.

An endovascular strategy for suspected ruptured abdominal aortic aneurysm brings earlier home discharge but not early survival or cost benefits.

Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC) Lyons, O. T. A., Baguneid, M., Barwick, T. D., Bell, R. E., Foster, N., Homer-Vanniasinkam, S., Hopkins, S., Hussain, A., Katsanos, K., Modarai, B., Sandoe, J. A. T., Thomas, S. & Price, N. M. 19 Sep 2016 In : European Journal of Vascular and Endovascular Surgery. Research output: Contribution to journal › Article

Type B aortic dissection after standard endovascular repair of abdominal aortic aneurysm.

Dissection of the aorta is a rare yet potentially serious complication following endovascular abdominal aortic aneurysm (EVAR). These can lead to visceral branch hypoperfusion, compromise of aneurysm exclusion, arterial dilation or rupture. Intimal injury and dissection in the context of EVAR may be associated with a number of risk factors that include adverse infrarenal neck morphology, device oversizing, barbed fixation and wire manipulation in the proximal aorta. Herein, we describe three cases of type B aortic dissection following EVAR and discuss possible causes. As the applicability of endovascular technology widens, clinicians are reminded of the importance of early recognition and detection of unusual sequelae following EVAR.